Case 3 - Hyperemesis Gravdium

Question 1

1. What is hyperemesis gravidarum?

Answer 1

A condition where vomiting is persistent and subsequently interferes with fluid intake and nutrition status resulting in malnutrition and or weight loss, fluid, electrolyte and acid-base imbalance.

hyperemesis gravidarum is characterised by persistent vomiting, volume depletion, ketosis, electrolyte disturbances, and weight loss (>5%).

With severe hyperemesis, the effects of electrolyte imbalances, vitamin deficiencies and inadequate nutrition can cause maternal and fetal morbidity.

cause - bhcg, oestrogen causng delayed gastric motility, change in ph –> helicobacter pylori infection, tsh

Question 2

2. How would you distinguish between hyperemesis gravidarum and ‘normal morning sickness’?

Answer 2

Nausea and vomiting in pregnancy (NVP) is a very common symptom (70-85% of pregnancies) and can be grouped in 3 categories
􏰀 Without volume depletion
o ‘normal morning sickness’ Most often, NVP tends to be mild and self-limiting, often occurring in the morning.
􏰀 With volume depletion and electrolyte imbalance
o Increasing severity
􏰀 Persistent vomiting, volume depletion and electrolyte imbalance, ketosis and >5% weight loss
o Hyperemesisgravidarum(0.5-2.0%ofpregnancies)Mostsevere

Question 3

3. What features of the history and examination of a woman with nausea and vomiting during
   pregnancy might indicate that admission and/or intravenous rehydration is required?

Answer 3

Admission and/or intravenous rehydration are required if:
Symptoms and clinical signs of ketosis, electrolyte imbalance and volume depletion.

Symptoms: Severe nausea with vomiting >3 times per day, smelly breath, unable to tolerate oral food/fluid, lethargy, oliguria, dry mouth, thirst
Signs:
􏰀 Dehydration: tachycardia, reduced skin turgor, dry mucosa, low JVP.
􏰀 Malnutrition: weight loss >5%, anaemia. Reduced level of consciousness

Question 4

4. What are the important ‘not-to-be-missed’ diagnoses – both differentials and causes of serious

Answer 4

Differentials
􏰀 Hyatidiform mole (Molar pregnancy)
􏰀 Multi-gestational pregnancy
􏰀 Hyponatraemia (normal causes - diuretics, heart failure, diahorrea, liver disease, renal disease, SIADH)
􏰀 Non-pregnancy causes of vomiting: hepatitis, pyelonephritis, appendicitis,
pancreatitis, cholecystitis, bowel obstruction, raised intracranial pressure,
hyperthyroidism, gestational trophoblastic disease

Question 5

5. What investigations would you consider when assessing a patient with hyperemesis gravidarum?
   Justify each one.

Answer 5

FBC - anaemia, infection
U+E - electrolyte imbalance
LFT - exclude alternative aetiologies

Urinalysis - ketonuira, rule out UTI/pyelonephritis

Radiology - fetal US (multiple pregnancies/other fetal abnormalities)

Question 6

6. What are evidence-based therapies for hyperemesis gravidarum?

Answer 6

1. admit to ward for monitoring (urine input/output), electrolyte status
2. IV fluids - 0.9% saline + potasium (also depends on eletrolights)
3. Folic acid, thiamine, pyridoxine
4. relief of symptoms
   metaclopramide, cyclizine or ondasetron.
5. Advice given - support and reassurance, diet and lifestyle - small dr mea,s, eat when nausea less severe, avoid aggravating foods, oral ginger, corticosteroids - in severe hyperemesis.

Question 7

7. How do we categorise drug safety during pregnancy? Where do the commonly used antiemetics fit?

Answer 7

a - good
b - maybe
c - risk of damage to fetus

Antihistamine Promethazine C Cyclizine A Phenothiazine Prochloperazine C Dopamine antagonist Metoclopromide A
Domperidone B2 Serotonin antagonist Ondansetron B1